Caring for the Geriatric Patient: What Oncology Nurses Need to Know
Oncology nurses must consider many factors when treating geriatric patients, from drug-drug interactions to treatment education and functional age.
Older age is a significant risk factor for many types of cancer. It is estimated that by 2030, 70% of patients with new cancer diagnoses will be 65 and older.1 It is imperative that nurses caring for geriatric patients understand the unique challenges their patients face to ensure that the care provided meets those needs.
In a recent interview with Oncology Nursing News®, Leana Cabrera Chien, MSN, RN, GNP-BC, and Jeanine Moreno, MS, APRN, AGNP-C, shared their insights on geriatric oncology nursing. Chien and Moreno, along with Carolina Uranga, MSN, RN, GNP, and Peggy Burhenn, MS, CNS, RN-BC, AOCNS, compose the Aging Wellness APN team at City of Hope Aging Wellness Clinic in Duarte, California, recently recognized by the Institute for Healthcare Improvement as an Age-Friendly Health System.
As a board-certified geriatric nurse prac-titioner (NP), Chien has worked with older adults with cancer and participated in studies about such patients in various settings with the goal of improving their model of care. Whereas oncologists focus on treatment, the role of the NP goes further, focusing on the whole patient.
“The biggest difference in older patients is they come with a whole history obtained over a longer period of time,” Chien said. “Look at the whole person, their comorbidities, nutritional deficits, functional and/or cognitive decline, falls, depression, and concerns such as fatigue, which may be associated with other issues.”
Conducting a comprehensive geriatric assessment will help clinicians evaluate and address age-related concerns and improve the quality of care they provide, individualized to meet the patient’s unique need. The American Society for Clinical Oncology (ASCO) Guidelines for Geriatric Oncology provide recommendations on the use of validated, standardized clinical assessment tools.2
Moreno, who is also a gerontological NP, heartily agrees. Before going to City of Hope, she had no experience working with patients with cancer, but merging her expertise in geriatrics with oncology has made her an invaluable asset.
“That first meeting to discuss a cancer diag-nosis is always overwhelming. It turns your world upside down, no matter your age or health,” Moreno said, adding, “Older adults, however, tend to face obstacles not typically experienced by younger patients.”
Comorbidities can also be affected by treatment, and vice versa. Patients with arthritis, for example, may experience flare-ups in pain from chemotherapeutic drugs. Education is key in helping patients understand that their existing conditions may change or be exacerbated in response to treatments. These conversations are ongoing and meant to help prevent additional problems from occurring.
Moreno encourages nurses to look at everything going on with a patient and how it relates to their status and safety. “If a patient’s knees hurt too much to stand and cook, they will not eat as much. If their blood pressure is too low, they may pass out and hit their head.” Thorough assessment will identify these issues before a problem develops or an incident occurs.
Polypharmacy is another obstacle common with older adults. Chien shared a story about a patient with cardiac issues who experienced dizziness and frequent falls: “A medication review revealed the patient was taking amiodarone and an antidepressant, which was curious because this patient was always happy, cheerful, and upbeat. When asked about the antidepressant, she said it had been prescribed to her years ago after her husband passed away and no one had told her to stop taking it. Once the medication was discontinued, the dizziness improved and the falls stopped.”
It is not enough to know which medications a patient is taking and why; nurses also need to know how medications may interact and what effects those interactions may have. What may seem minor can make a big difference.
Medication review includes both prescription and OTC drugs, looking at appropriateness, dosages, frequencies, effectiveness, and adverse events (AEs). Medications may need adjustments during treatment because of drug-drug interactions or patient status. Communication between members of the multidisciplinary team (primary care physician, pharmacist, oncologist, cardiologist, nursing, therapy, nutrition) when updating medication regimens or changes in condition helps ensure consistency and safety.
Cancer treatments are not easy, even for the young patient. Since Moreno began working in oncology, she has been shocked by how much a person can physically endure. Sometimes the decision is based on the wishes of their family. “Even when the prognosis is not great, some patients consent because it’s what their loved one wants,” she stated. Other patients may choose a different course, or one that the health care team may not think is best. Nurses need to honor whatever choice the patient makes, provided education about all the options available including risk and benefit has been given to the patient to make an informed choice. Sometimes the choice may be to forgo treatment. Patients may be unaware that declining treatment is also an option.
Discussions on toxicity are important with patients considering chemotherapy. A validated chemo-toxicity calculator (along with a geriatric assessment tool) is available from the Cancer and Aging Research Group at www. mycarg.org. The toxicity calculator captures socio-demographics, tumor/treatment variables, lab results, and geriatric assessment items to predict the risk of severe AEs of chemotherapy in older adults that can guide decision-making.
When looking at patients, consider their functional age, not merely chronological age. Two 90-year-old patients can differ greatly in their functional ability. “This is a huge teaching point for nursing staff,” says Moreno. “Some 90-year-olds are highly functioning, whereas some 65-year-olds are not.” Part of treatment includes preventing functional loss. Balancing rest with activity can be challenging, especially for patients over 85. They may be more afraid of moving or falling, which can be addressed through physical and/or occupational therapy. A key teaching point for both patients and family members is the importance of mobility to prevent loss of muscle mass.
A recent pilot study conducted at Duke University testing the effectiveness and feasibility of academic-practice partnership for caregiver training and support demonstrated favorable outcomes for caregivers and older patients.3 The program included training on medical tasks in the home as well as follow-up phone calls to caregivers. Programs like this may be helpful prototypes for oncology nurses to consider for adaptation to the special needs of older patients and their families.
Communication and Technology
Older adults may have struggles with communication because of hearing deficits or cognitive decline, but what about technology? Are older adults less tech savvy than younger adults? Perhaps, but Moreno and Chien have found that most older adults can and do use computers. Research suggests the challenge is related more to resource limitations than ability or reluctance.4
Resource limitations may apply to patients of any age, not just older adults. Since the COVID-19 pandemic, however, families have had to adjust to social restrictions, and have learned to use video platforms such as Zoom to visit and communicate with their loved ones. What may be a bigger hindrance to digital communication than technical savvy is poor internet service, especially in areas that are more rural.
Face-to-face communication is always best, but telehealth has become a valuable tool for health care providers, patients, and their family members. Televideo allows providers to conduct geriatric assessments remotely, to see patients’ home environments, check their medicine cabinet, talk with multiple family members, and can ease the challenges of transportation for the older adult, especially when multiple appointments are needed. Physical and occupational therapy sessions may also be conducted via telehealth to increase strength and mobility.
For patients less adept with using technology, nurses should take the time to walk a patient through the app/resource/program they will be using. Some patients may not have a computer or a smartphone, and accommodations could be made with family members to bring a laptop to the patient’s home and assisting with its use.
Multiple phone calls between provider and patient are commonplace in oncology. For older adults, they may need encouragement from family to make a call with a question or concern. More than 1 call may be necessary to change a routine or reiterate important information. Nurses find family input helpful, as they add to the conversation and provide information from a different perspective.
Symptom monitoring technologies may also be helpful for older patients with cancer. A recently published study demonstrated that older adults had the same level of adherence as younger adults, and received similar benefits, using a telephone-based intervention, which did not require smartphones, computers, or Wi-Fi.4 The keys to effective, responsive communication are ensuring that methods used fit the patients’ needs and that messages are communicated clearly and received and understood as intended.
Opportunities for Growth
Oncology nurses will be best prepared to provide high-quality, individualized care to their older adult patients by becoming familiar with geriatric guidelines and assessment and learning more about age-related concerns of geriatric patients. Information and education is available from Nurses Improving Care for Healthsystem Elders at www.nicheprogram.org, the National Comprehensive Cancer Network at www.nccn. org and for providers at American Geriatrics Society at www.americangeriatrics.org.
1. Presley CJ, Krok-Schoen JL, Wall SA, et al. Implementing a multidisciplinary approach for older adults with cancer: geriatric oncology in practice. BMC Geriatr. 2020;20(1):231. doi:10.1186/s12877-020-01625-5
2. Mohile SG, Dale W, Somerfield MR, et al. Practical assessment and management of vulnerabilities in older patients receiving chemotherapy: ASCO guideline for geriatric oncology. J Clin Oncol. 2018;36(22):2326-2347. doi:10.1200/JCO.2018.78.8687
3. Hendrix CC, Matters D, Griffin T, et al. Academic-practice partnership for caregiver training and support: the Duke Elder Family/Caregiver Training (DEFT) Center. N C Med J. 2020;81(4):221-227. doi:10.18043/ncm.81.4.221
4. Coombs LA, Ellington L, Fagerlin A, Mooney K. Age is not a barrier: older adults with cancer derive similar benefit in a randomized controlled trial of a remote symptom monitoring intervention compared with younger adults. Cancer Control. 2020;27(1):1073274820968878. doi:10.1177/1073274820968878